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PLEASE PRINTName:Date of Birth:Gender:If State Employee/Retiree, State Health Insurance Plan:If State Employee/Retiree, Last Four Digits of SSN:XXX-XXIf Patient, Patient I.D. Number:If Patient, Assigned Unit:Nurse/Physician Obtaining Consent Printed Name:Nurse/Physician Signature:Date/Time:COVID-19 SectionYESNON/AI have received the COVID-19 Vaccine Information Statement:Are you currently feeling sick, such as experiencing a fever?Do you have allergies to latex, food, medications, vaccines, or vaccine components? If Yes, specify:Have you ever had a serious reaction after receiving a vaccine?Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?If yes, please describe: During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or any antiviral drug? Do you have a weakened immune system?In the last 3 months, have you taken medications that weaken your immune system (e.g. prednisone, other steroids, or anticancer drugs) or received radiation treatments? Are you currently pregnant or considering becoming pregnant in the next month?Have you received the COVID-19 vaccine this season?Have you received any other vaccinations within the last 4 weeks?If yes, please describe:COVID-19 Consent I have read, or had explained to me, the Vaccine Information Statement about the COVID-19 Vaccination from the Centers for Disease Control (CDC). I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. _____________________________________________Receiver of Vaccine/Guardian Printed Name Date _____________________________________________Receiver of Vaccine/Guardian Signature Date AREA TO BE COMPLETED BY NURSECOVID-19 Vaccine:COVID-19 Vaccine Contraindicated: Yes NoAdministration Date/Time: Administration Site:12928609842500Left ArmRight Arm2435860-12700000243586010096500Left ThighRight Thigh ManufacturerLot NumberExp. Date37528511938000Nurse's Printed Name Nurse's SignatureDate AREA TO BE COMPLETED BY NURSE (For Patient Refusals)COVID-19 Vaccine:60388541084500197548541084500Date Offered and Declined:Nurse Initials: 1.2. ................
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